April is national occupational therapy month and its purpose is to spotlight the importance of occupational therapy and what it entails. It's a message that some experts say needs to resonate more clearly in the eldercare environment. That includes the skilled nursing realm.

While occupational therapy is a common modality in long-term care—prominently offered as a resident service alongside physical and speech therapy—most would agree it's the most misunderstood and, in some cases, underappreciated of the three. Residents and their family members, but also some administrators, nursing directors, frontline caregivers and even physical therapists are guilty of underestimating the gravity of an OT program.

“There remains a level of uncertainty within the community and with fellow medical professionals regarding the scope of occupational therapy,” confirms Jennifer Calabrese, director of occupational therapy clinical services for Cherry Hill, NJ-based Fox Rehabilitation.

Part of the problem, she says, is the misinterpretation of the term “occupation” by non-medical professionals. “This misconception indicates a need for additional education.”

Occupational therapists may simultaneously struggle with other lingering misconceptions, including the notion that occupational therapy is merely an adjunct to physical therapy. The growing emphasis on exercise and physical functioning in the senior population—although beneficial—can blur the distinction between occupational and physical therapy, says Thomas J. Mernar, assistant professor of occupational therapy at the Seton Hall School of Health & Medical Sciences, South Orange, NJ.

Further muddying the waters is the assumption that occupational therapists predominantly target the upper body while physical therapists focus largely on the lower extremities.

“It's a common belief but one that couldn't be further from the truth,” explains Cathy Loose, an occupational therapist for St. Louis-based RehabCare Group Inc. “Occupational therapists do so much more than that.”

Overcoming obstacles

Sometimes, occupational therapy takes a backseat to physical therapy because some individuals consider basic physical functioning to be the ultimate end point. While maintaining or regaining physical function is certainly valuable, occupational therapy helps take that goal a step further.

While officially defined by the American Occupational Therapy Association as the therapeutic use of work, self-care and play activities to increase development and prevent disability, here's a simpler description: occupational therapy helps residents live life to the fullest by focusing on activities most meaningful to each individual.

How a person occupies his or her time can typically be divided into several categories of daily activities: self-care, which involves sleeping, eating, dressing, grooming and toileting; work, which pertains to the effort required to perform a task; and leisure, which involves free time spent any way an individual chooses (such as knitting, socializing, reading, watching movies or playing games).

“Basically, occupational therapy addresses anything that occupies a person's time,” says Loose. “If any daily activities become disrupted, [whether by age, illness,] injury or disability, occupational therapists can step in to help them become as functional and independent as possible with these activities.”

Although physical activities and exercises may be an important part of an occupational therapy session, it's typically geared toward assisting residents with more specific goals and tasks—such as dressing oneself, standing freely at the sink to brush their teeth, or perhaps even holding a pencil so they can continue journaling or sketching.“We may not get as much attention or respect as PT because

people associate PT with walking, and many people believe that walking is the most important thing. But if you cannot get dressed, where are you going to be walking to?” reasons one occupational therapist.

It's ultimately up to the occupational therapists to educate residents, families and caregivers on the benefits of participating in daily functional activities, such as planning a bathing task, obtaining the proper items, setting up the shower, washing, drying and dressing oneself, and the positive impact these activities have on overall body structure and function.

“One of the most common mistakes in OT delivery is the underutilization of activities of daily living to maximize functional outcomes,” stresses Calabrese. “Direct participation in basic self-care activities, such as toileting and grooming, as well as instrumental activities, such as meal preparation and money management, in a [resident's] own environment helps to encourage feelings of confidence and accomplishment.”

Another mistake occupational therapists make is failing to keep nursing staff apprised of therapy goals and progress.

“Communication is critical,” Loose notes.

“Nurses and assistants may be used to doing everything for a resident, so we need to let them know what we're trying to accomplish with therapy and what residents are able to do on their own. That way, we can become partners in the process.”

Mind-body connection

Cognition and perception elements largely factor into occupational therapy, which further distinguishes the discipline from physical therapy. Addressing cognitive issues helps residents thrive in physical therapy, as well, by building confidence and breaking down mental barriers that may inhibit their ability to fully engage in beneficial activities, reasons Sherry Ford, administrator for Sharon Homes Elms, a Barton Healthcare facility in Peoria, IL.

“I'd say the most misunderstood aspect of occupational therapy is the cognitive element—how fear and perception issues can impact a person's well-being and their ability to perform and [embrace] activities to maintain quality of life,” she says. “If a person is afraid of falling, for example, they may not want to participate. Occupational therapy can help people work through those fears, so they can benefit most from their sessions and regain function faster.”

At the same time, she says, strength-building activities in physical therapy may make it easier for a resident to participate in more specific activities being sought after in occupational therapy.

OT experts agree that the most effective programming follows evidence-based practice. Increased participation in evidence-based research helps clinicians ensure that the data being measured and analyzed is directly relevant to the daily challenges that occupational therapists face, Calabrese notes. Further, the use of functional outcome measures can lead to more accurate resident assessment, while guiding more effective treatment for successful outcomes.

“The American Occupational Therapy Association has established a goal to initiate a national database to make OT outcomes more accessible by 2011,” she says, looking ahead.

Above all, occupational therapists should follow a highly focused, individualized therapy approach that takes into consideration residents' psychological, physical, emotional, and social make-up—as well as their current environment. Comprehensive resident evaluations play an important role in determining interests, hobbies and daily activities that the resident engaged in prior to their decline.

“Their diagnosis really doesn't matter,” Loose says. “Even if they can't verbalize their interests and activities themselves, you can learn important things from their family members to help with the direction of their therapy.”

Initially, she favors one-on-one sessions and then adds in occasional concurrent sessions and at least once-weekly group sessions, which assist with socialization.

Group sessions may help uncover similar interests, which may further boost the therapy's effectiveness. In one such session, Loose discovered that three men shared an interest in planes.

“One was in an Alzheimer's unit and had difficulty communicating, but I used pictures of planes in a book to engage him,” she recalls. “I was able to use that information to reach him in a more meaningful way.”

She also shared the men's mutual interest in planes with the activities director to help keep the momentum going.“It can be difficult to get residents to participate, but people tend to like to talk about their past. It helps them with their socialization and communication skills—and even if they can't communicate easily, it helps them feel connected.”

Expanding OT's horizons

Increasingly, occupational therapists are broadening their professional scope. They're becoming specialized in the field of low vision, home modification and community wellness programs, for example.

The Bureau of Labor and Statistics states that the job outlook for occupational therapy is healthy, especially in the field of geriatrics, and that employment is expected to grow faster than the national average.

“Occupational therapy retention is highest when individuals feel that they are a valued part of an integral treatment team and can directly see the correlation of their work with positive [resident] outcomes,” Calabrese says.

She adds that occupational therapists are playing a greater role in advocating for support in the areas of public policy, reimbursement and the scope of practice within their own licensure.

He further points out that OT programs would be more effective if occupational therapy played a direct role in determining the appropriate resource utilization group (RUG) level of a resident, as opposed to being told what RUG level they need to achieve.

“Sometimes, the RUG levels for a given [resident] are too high for the client's current level of function,” he explains.

While being more ingrained in the treatment team and staying abreast of regulatory issues and evidence-based research will play an important role in defining occupational therapy's value in resident care, a history of positive outcomes will ultimately drive appreciation and understanding of the discipline.

“Respect is earned,” stresses Mernar. “If the occupational therapist is generating good rehabilitative outcomes and is good at educating clients, families and other healthcare practitioners on their focus and value, then respect should naturally emerge.”

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